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Psychological treatment for anxiety in people with traumatic brain injury

  1. Cheryl Soo1,*,
  2. Robyn L Tate2

Editorial Group: Cochrane Injuries Group

Published Online: 18 JUL 2007

Assessed as up-to-date: 1 MAY 2007

DOI: 10.1002/14651858.CD005239.pub2


How to Cite

Soo C, Tate RL. Psychological treatment for anxiety in people with traumatic brain injury. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005239. DOI: 10.1002/14651858.CD005239.pub2.

Author Information

  1. 1

    University of Sydney and Royal Rehabilitation Centre Sydney, Rehabilitation Studies Unit, Ryde, New South Wales, Australia

  2. 2

    The University of Sydney, Rehabilitation Studies Unit, Northern Clinical School, Sydney Medical School, Ryde, New South Wales, Australia

*Cheryl Soo, Rehabilitation Studies Unit, University of Sydney and Royal Rehabilitation Centre Sydney, PO Box 6, Ryde, New South Wales, 1680, Australia. csoo4154@mail.usyd.edu.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 JUL 2007

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Anxiety is common in the general population and individuals with traumatic brain injury (TBI) are thought to be at increased risk of developing the condition (Hiott 2002). Anxiety may manifest as symptomatology, which is frequently linked to the process of adjustment to the injury and may present as a feeling of apprehension or fear, or as a diagnosable disorder such as post-traumatic stress disorder (PTSD) or obsessive compulsive disorder (OCD). The consequences of anxiety following brain injury are far reaching, negatively impacting upon rehabilitation outcomes, functional ability, interpersonal relationships and employment outlook. A biopsychosocial model of adjustment after injury has been proposed for the development of post-TBI anxiety (Gainotti 1993; Kendall 1996; Lishman 1973). Within this model, the role of direct (medical, neurological and neuropsychological) and indirect (biographic, personal and environmental) antecedent factors are emphasised, with both direct and indirect components often playing a role in the development of emotional problems (Lishman 1973). Mediating factors are also highlighted with variables such as cognitive appraisals and coping and adjustment styles of the individual interacting with these antecedent factors (Kendall 1996).

It is often difficult to accurately determine the occurrence of anxiety disorders following TBI because the clinical presentation of people with TBI is complex (Williams 2003a). Individuals with TBI commonly have difficulties in cognitive, behavioural and emotional functioning (Ponsford 1995). These problems frequently overlap with presentation of anxiety symptoms, with the severity of the TBI compounding the level of anxiety. Estimates of how frequently anxiety symptoms occur following TBI range from 18% to 60% (Hibbard 1998). Studies examining specific anxiety disorders have found that in people with brain injury, 24% to 27% were diagnosed with generalised anxiety disorder and 4% to 6% with panic disorder (Fann 1995; Van Reekum 1996). Bryant 2000 found that 27.1% of patients who sustained a severe TBI developed post-traumatic stress disorder at six months after the injury.

A number of approaches have been developed for the psychological management of anxiety; for example, cognitive behavioural therapy (CBT), psychoanalytic therapy and psycho-education. Psychological-based treatments are commonly used in the management of anxiety in individuals with and without a brain injury (Hiott 2002; Hodgson 2005; Williams 2003a). Indeed, certain psychological interventions (for example, CBT) have been found to be clearly effective for the management of anxiety in general mental health groups (Deacon 2004). Some have argued that CBT is well suited to the needs of people with TBI because of the structured nature of the treatment (Manchester 2001; Ponsford 1995); however, these programs require adjustment to account for difficulties related to the TBI (for example, memory and executive impairments as well as inability to make day-to-day decisions).

In terms of non-psychological interventions, pharmacotherapy is also used in the management of anxiety with or without psychological treatments (Balon 2004). It has been noted, however, that an increased risk of medical side effects (for example, nausea, dizziness and insomnia) has been reported with pharmacological treatments in the TBI population, and hence psychological treatments may be preferred during the initial phase of anxiety treatment (Hiott 2002). Cognitive side effects of pharmacological treatments (for example, slowed information processing speed) have also been reported, further attenuating already compromised cognitive functioning. Other less commonly used treatments include psychosurgery (Ruck 2003) and complementary and alternative therapies, such as aromatherapy and homeopathy (Kessler 2001); however, empirical evidence for the effectiveness of these alternative treatments for TBI populations is very limited.

 

Why it is important to do this review

Given that psychological treatments for anxiety require specialised adaptation for the individual needs of people with TBI, few randomised controlled trials have examined the efficacy of these specific programs. However, because these treatments are commonly used and are recommended in the management of anxiety in people with neurological conditions (Williams 2003a), it is important to evaluate the empirical evidence that currently exists in this area. Although a number of narrative reviews focusing on the treatment of anxiety in general mental health groups have been published (Balon 2004; Deacon 2004), to date there are very few systematic reviews focusing on anxiety interventions. In particular, there is no systematic review focusing on treatment of anxiety in TBI and hence the strongest level of evidence is not available. This systematic review examines the evidence for psychological treatments for anxiety in people with TBI. Focus is placed on anxiety symptomatology as well as diagnosis of specific anxiety disorders. The results of this review can assist clinicians in the management of these conditions for people with TBI.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

To determine whether psychological treatment for anxiety (with or without pharmacological treatment) in people with TBI is superior to the following:

  • no psychological treatment for anxiety with no pharmacological treatment for anxiety;
  • no psychological treatment for anxiety with pharmacological treatment for anxiety.

In addition, if trials were available, different psychological treatments for anxiety in people with TBI were be compared to determine which psychological treatment was superior.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All randomised controlled trials (RCTs) in which psychological treatment for anxiety in people with TBI were examined were included in this review.

 

Types of participants

People with TBI aged five years and over were the focus of this review. People with acquired brain impairment other than TBI (for example, stroke) were not included. Trials using a mixed sample of participants with different neurological conditions were included if the majority (80% or greater) of the sample comprised individuals with TBI.

A TBI was defined as a traumatically-induced physiological disruption of brain function, as manifested by at least one of the following (Kay 1993):

  1. any period of loss of consciousness;
  2. any loss of memory for events immediately before and after the trauma;
  3. any alteration in mental state at the time of the trauma (for example, feeling dazed, disorientated or confused); or
  4. focal neurological deficit(s) resulting from the trauma that may or may not be transient.

All levels of severity of TBI were included as defined by Glasgow Coma Scale (GCS) scores, duration of post-traumatic amnesia (PTA), radiological measures or other standard indices of severity.

Anxiety included both diagnosis of anxiety disorders as well as anxiety symptomatology, as follows:

  • diagnostic criteria of the Diagnostic Statistical Manual - fourth edition (DSM-IV) (APA 1994) or International Classification of Diseases (ICD) (WHO 1992), including one or more of post-traumatic stress disorder, acute stress disorder, generalised anxiety disorder, obsessive compulsive disorder, overanxious disorder, panic disorder, agoraphobia, separation anxiety disorder, selective mutism, specific phobia, social phobia and school phobia; or
  • anxiety symptomatology as indicated by self report or observer report on standardised and non-standardised questionnaires. In cases where studies allowed, specific tables categorising different anxiety diagnosis and stratification of studies by age group (5 to 12 years, 13 to 17 years, 18 to 64 years and 65 years plus) were included. Individuals with concurrent diagnosis of depression were also included. Those who were taking concurrent medications for physical illnesses (for example, anti-hypertensive drugs) were not excluded.

 

Types of interventions

Any form of psychological treatment aimed at reducing anxiety, with or without pharmacological treatment, were included in the review.

Psychological treatments included behaviour therapy, cognitive therapy, psychoanalytic therapy, education, counselling, social skills training, cognitive rehabilitation, neurorehabilitation or other (for example, family therapy). There was no restriction on the duration of treatment.

Pharmacological treatments for anxiety in isolation (without psychological therapy) were excluded. Pharmacotherapies included were those aimed at reducing anxiety, for example, antidepressants and benzodiazepines (only included when pharmacotherapies were combined with psychological therapies).

 

Types of outcome measures

 

Primary outcomes

  • Diagnostic status of anxiety as determined by use of a standardised structured interview or scale.
  • Self or observer report of symptoms of anxiety using standardised and non-standardised questionnaires.

 

Secondary outcomes

  • Neuropsychological functioning, psychosocial adjustment, everyday functioning and psychosocial or community participation.
  • Medication usage, service usage.
  • Treatment compliance, as indexed by the number of withdrawals or drop-outs.

 

Search methods for identification of studies

 

Electronic searches

We searched the following electronic databases.

  • Cochrane Injuries Group's (CIG) specialised register
  • Cochrane Collaboration Depression, Anxiety and Neurosis's (CCDAN) specialised register
  • Cochrane Central Register of Controlled Trials (CENTRAL) (search last performed March 2006)
  • Database of Abstracts of Reviews of Effects (DARE) (search last performed March 2006)
  • MEDLINE (1966 to March 2006)
  • PsycINFO (1967 to March 2006)
  • EMBASE (1980 to March 2006)
  • CINAHL (1982 to March 2006)
  • PsycBITETM (search last performed March 2006)
  • AMED (1985 March 2006)
  • ERIC (1966 to March 2006)
  • general Internet search

Studies were identified by literature searches combining the following three areas.

 
Traumatic brain injury

The following MeSH terms were exploded: traumatic brain injury, craniocerebral trauma, brain injury(ies), head injury(ies), brain disease, brain damage.

The following text words were used: (brain or head or cranial adj1 trauma), (brain or head or cranial adj1 injur$), (brain or head or cranial adj1 damage), (brain or head or cranial adj1 disorder$).

 
Diagnosis or symptomatology of anxiety

The following MeSH terms were exploded: anxiety, anxiety disorder(s), separation anxiety, self-rating anxiety scale, anxiety neurosis, generalised anxiety disorder, "mixed anxiety and depression", anxiety management, social anxiety.

The following text words were used: anxiety, overanxious, anxiety disorder, anxious, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, overanxious disorder, panic disorder, agoraphobia, separation anxiety disorder, selective mutism, phobia.

 
Psychological intervention

The following MeSH terms were exploded: behavio$r therapy, cognitive therapy, psychoanalytic therapy, family therapy, psychotherapy, therapy, rehabilitation, program evaluation, treatment outcome(s), intervention trials, psychiatric treatment, intervention, intervention studies, therapeutics, treatment, psychotherapeutic techniques.

The following text words were used: psychological (training, treatment$, rehab$, remed$, program$, interven$, therap$, approach$, techniq$, modificat$, strateg$, manag$), cognitive therapy, behavio$r therapy, psychotherapy, psychodynamic, family therapy, education, counseling, social skills training, cognitive rehabilitation, neurorehabilitation, relaxation, exposure.

Full search strategies are listed in Appendix 1.

 

Searching other resources

 
Reference lists

References lists of the articles identified from the literature searches above were examined for any further studies that met the inclusion criteria.

 
Personal Communication

Researchers who have already conducted trials in this area were contacted to identify other published or unpublished trials.

 
Handsearches

Key journals were handsearched and included the following.

  • American Journal of Psychiatry (1986 to 2006)
  • Archives of Physical Medicine Rehabilitation (1986 to 2006)
  • Brain Injury (1987 to 2006)
  • British Journal of Clinical Psychology (1986 to 2006)
  • Journal of Head Trauma Rehabilitation (1986 to 2006)
  • Journal of Neurology, Neurosurgery, and Psychiatry (1986 to 2006)
  • Neuropsychological Rehabilitation (1991 to 2006)
  • Psychological Medicine (1986 to 2006)
  • British Journal of Psychiatry (1986 to 2006)

 
Grey literature

We searched for unpublished trials using the following resources: National Research Register, www.controlled-trials.com, www.clinicaltrials.gov, www.actr.org.au/trial. We also examined researchers' references and proceedings of key conferences.

The searches were not restricted by language or publication status.

 

Data collection and analysis

 

Selection of studies

The two authors separately and independently inspected all citations identified by electronic database searching. The title and abstracts were assessed to determine whether each article met the predetermined criteria. In brief the criteria comprised the following:

  • participants were over five years of age,
  • psychological treatment targeting anxiety was employed,
  • participants sustained a TBI, and
  • study was an RCT.

In case of doubt or disagreement, the full article was obtained for inspection. Identified articles were then obtained and independently assessed to confirm that they meet review criteria. Identified studies were tracked by an electronic reference management system (EndNote).

 

Data extraction and management

Data were extracted from the trial reports by two authors and results compared. In cases where information was missing or was unclear from the report, the original investigators were contacted.

 

Assessment of risk of bias in included studies

Quality of trials was independently rated by the two authors using the PEDro scale (Maher 2003), which is based on the Delphi list (Verhagen 1998). The PEDro scale includes the following 11 items:

  1. specification of eligibility criteria,
  2. random allocation of participants to groups,
  3. concealed allocation,
  4. group similarity at baseline regarding most important prognostic indicators,
  5. blinding of all participants,
  6. blinding of all therapists who administered the therapy,
  7. blinding of all assessors who measured at least one key outcome,
  8. measurement of at least one key outcome obtained from more than 85% of participants,
  9. all participants for whom measures were available received the treatment or control condition as allocated or data for at least one key outcome was analysed by 'intention-to-treat'
  10. reporting of between-intervention group statistical comparisons for at least one key outcome,
  11. reporting of point measures and measures of variability for at least one key outcome.

Items 2 to 11 are used to obtain a method quality score. The reliability of the PEDro scale has been examined between independent raters with Kappa values for each of the 11 items ranging from 0.36 to 0.80 (Maher 2003).

In the event of disagreement of quality ratings between the two authors, discussions were held to reach a consensus.

 

Data synthesis

Subgroup analysis based on the type of anxiety diagnosis was not conducted because only one study was identified which included participants diagnosed with an anxiety disorder.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

The most current search on electronic databases was conducted in March 2006 and this yielded a total of 3038 references. A total of three RCTs were identified which met the inclusion criteria. An additional 25 trials addressing anxiety after acquired brain injury were identified but these were excluded because they were either not an RCT or did not include a sample consisting of 80% or greater of participants with TBI. Investigation of other specified sources for identifying studies yielded no additional studies meeting inclusion criteria. Two of three identified trials, by Bryant 2003 and Tiersky 2005, met inclusion criteria from information reported. The third trial by Helffenstein 1982 did not explicitly state that participants of the study included people with TBI. After correspondence with the trial author it was confirmed that all study participants had sustained a TBI and the trial was included in the review.

The three included studies examined the corresponding group comparisons as follows.

  1. CBT versus supportive counselling (SC) (Bryant 2003).
  2. Interpersonal process recall (IPR) therapy versus controls with no feedback on interpersonal functioning (Helffenstein 1982).
  3. CBT combined with neurorehabilitation (NR) versus no psychological intervention controls (Tiersky 2005).

Bryant 2003
This study examined psychological therapy for people with mild TBI diagnosed with a specific anxiety disorder (acute stress disorder) comparing CBT (n = 12; eight females) and SC (n = 12; eight females) groups. The mean (SD) age for the CBT group was 29.4 (13.9) years and for SC group was 33.0 (14.4) years.  Table 1 Primary outcome measures were;

  • Clinician Administered PTSD Scale (CAPS) frequency and intensity subscales,
  • Impact of Event Scale (IES) intrusions and avoidance subscales, and
  • Beck Anxiety Inventory (BAI).

Helffenstein 1982
This study examined 13 males and three females with TBI aged between 17 and 35 years.  Table 2 Severity of TBI of participants was not indicated. IPR therapy (n = 8) and control (n = 8) groups were examined using the State-Trait Anxiety Inventory (STAI; state and trait forms) as the primary outcome measure.

Tiersky 2005
This study focused on mild to moderate TBI comparing CBT and NR (n = 11; five females) and control (n = 9; six females) groups.  Table 3 The primary outcome measure was the anxiety subscale of the Symptoms Checklist - 90R (SCL-90R). Mean (SD) age of participants in CBT and NR and control groups were 47.55 (11.78) and 46.00 (9.35) years respectively.

 

Risk of bias in included studies

Methodological quality for the RCTs was independently rated by two authors using the PEDro scale (Maher 2003). The mean kappa coefficient between the two raters for total PEDro scores for the three included studies was 0.81. Kappa coefficients for each of the three studies were: 1 (P < 0.001) for Bryant 2003, 0.65 (P < 0.05) for Helffenstein 1982 and 0.79 (P < 0.01) for Tiersky 2005. Scores for each item on the PEDro scale for the three included studies were reported in  Table 4. Both studies by Bryant 2003 and Tiersky 2005 achieved a total score of 6/10 and the study by Helffenstein 1982 achieved a total score of 3/10.

Performance of the three studies on the 11 items of the PEDro scale were as follows.

  1. all three studies specified eligibility criteria for study inclusion,
  2. all three studies randomly allocated participants to interventions,
  3. only the study by Tiersky 2005 stated that allocation to interventions was concealed,
  4. studies by Bryant 2003 and Tiersky 2005 indicated that intervention groups were similar at baseline regarding the key outcome measures and most important prognostic indicators,
  5. there was no blinding of subjects in any of the three studies,
  6. there was no blinding of therapists who administered the therapy in any of the three studies,
  7. all three studies blinded assessors who measured at least one key outcome,
  8. studies by Bryant 2003 and Helffenstein 1982 indicated adequate follow up with at least one key outcome obtained from more than 85% of participants initially allocated to groups, whereas Tiersky 2005 followed up only 69% of participants,
  9. none of the three trials stated that all participants received the treatment or control condition as allocated or that data for at least one key outcome were analysed by intention-to-treat principles,
  10. and 11. studies by Bryant 2003 and Tiersky 2005 reported results of between-intervention group statistical comparisons, as well as point measures and measures of variability for at least one key outcome.

 

Effects of interventions

There was too much heterogeneity among the studies to permit meta-analysis. Specifically, the study populations and interventions of the three identified studies were judged to be sufficiently inconsistent to allow pooling of the data. The study by Bryant 2003 was examined separately because it included participants diagnosed with acute stress disorder, whereas the studies by Helffenstein 1982 and Tiersky 2005 did not include participants with a diagnosed anxiety disorder. Rather, these two studies targeted participants with anxiety symptomatology. The interventions examined by Helffenstein 1982 and Tiersky 2005, however, were also too dissimilar to allow pooling of data. The intervention in the study by Helffenstein 1982 focused on interpersonal communication and interaction whereas the intervention examined by Tiersky 2005 was broader, encompassing both CBT and neurorehabilitation. ( Table 5;  Table 6)

Bryant 2003
This study examined psychological therapy for people with mild TBI diagnosed with a specific anxiety disorder, comparing CBT and SC groups which were similar at baseline in terms of anxiety symptomatology and presence of acute stress disorder. Post-treatment and six-month follow-up scores on anxiety outcome measures, controlling for pre-treatment symptom severity, were compared across groups. Results indicated that fewer participants met the criteria for post-traumatic stress disorder (PTSD) in the CBT group than the SC group, both at post-treatment (χ2 = 6.75, df = 1, P < 0.05) and six-month follow up (χ2 = 4.44, df = 1, P < 0.05). Additionally, significant differences were found between groups at post-treatment on the CAPS frequency (F = 12.88, df = 1, 23, P < 0.01) and intensity (F = 11.54, df = 1, 23, P < 0.01) subscales, IES intrusions (F = 9.44, df = 1, 23, P < 0.01) and avoidance (F = 47.49, df = 1, 23, P < 0.01) subscales and the BAI (F = 3.99, df =1, 23, P = 0.05) with the CBT group achieving lower (better functioning) scores compared to the SC group on all of these measures. Maintenance of treatment gains were reported at six-months follow-up, particularly in relation to PTSD symptoms, with the CBT group achieving significantly lower scores on the frequency (F = 5.40, df = 1, 23, P < 0.05) and intensity ( F = 6.75, df = 1, 23, P < 0.05) subscales of the CAPS and the intrusions (F = 6.26, df = 1, 23, P < 0.05) and avoidance (F = 9.58, df = 1, 23, P < 0.01) subscales of the IES. There was, however, no evidence of maintenance of gains in terms of anxiety symptomatology, with no significant difference between groups on BAI scores at the six-month follow-up assessment.

Helffenstein 1982
Comparison between IPR therapy and control groups in the second study showed a greater reduction in reported anxiety as measured by the STAI-trait form in the treatment group (F = 7.55, df = 1, 14, P = 0.02). No statistically significant differences in the reduction of anxiety were found on the STAI-state form. This study, however, did not appear to perform a between-group statistical comparison on the anxiety measures, examining only within group comparison across time.

Tiersky 2005
The third study compared CBT with NR and control groups using univariate analyses of covariance with baseline average as a covariate. Significant effects were found for anxiety as indexed by the SCL-90R anxiety subscale with lower levels of anxiety in the treatment group (P < 0.05).

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Principal findings

The aim of this review was to identify effective psychological interventions for management of anxiety following TBI. Unfortunately, only three identified trials focusing on distinct areas of the literature were found and therefore it was not possible to meaningfully pool data across studies. This review focuses on three interventions in the context of the particular participant characteristics of each of the trials.

There was support for the effectiveness of treating acute stress disorder using CBT techniques following mild TBI in comparison to a SC control group. Improvements were found in general anxiety symptomatology, anxiety symptomatology related to PTSD and less frequent diagnosis of PTSD. Therapy gains assessed at post-intervention were also maintained at six-months follow up, particularly with respect to PTSD but not for general anxiety symptomatology. Overall, the methodological quality of the trial investigating this comparison was moderate. The study investigators, however, did not state whether random allocation of participants to groups was concealed or whether participants for whom outcome measures were available received the treatment or control condition as allocated. It is possible that trial findings may be biased for these reasons.

There is also evidence for the use of combining CBT and NR for targeting general anxiety symptomatology in people with mild to moderate TBI. A methodological strength of the trial investigating these techniques was concealed random allocation of participants to treatment groups. Although overall methodological quality of this study was moderate, the trial may have been affected by an inadequate number of participants being assessed at post-treatment (69%) and by participants for whom outcome measures were available not receiving the treatment or control condition as allocated.

Limited empirical support was found for IPR therapy compared to controls who received no interpersonal skills feedback. Although general anxiety levels were reduced in the IRP group, the methodological quality of the trial that examined this comparison was compromised. This trial is highly subject to bias because it is unclear whether random allocation to groups was concealed, if IPR and control groups were similar at baseline regarding the key outcomes, and if between-group statistical comparisons examining IPR and control groups were conducted. Given that the methodological quality of this trial is compromised, focus was placed on the other two identified studies.

 

Strengths and weaknesses of findings

In interpreting the results of the review it is important to keep in mind that assessing anxiety in TBI populations is complex. Difficulties in assessment apply in particular to differential diagnosis of symptoms of anxiety disorders in people with TBI; for example, the overlapping symptoms of obsessive compulsive disorder with the inflexible behaviour often characterised by people with brain injury (Williams 2003a). Assessment of anxiety is further complicated by the availability of appropriate anxiety measures for people with brain injury. Anxiety scales, including those used in the trials of this review, have typically been developed for non-TBI populations and may have limited validity for people with brain injury (Bowen 1998), thus increasing the possibility of false classifications occurring. Additionally, the distinction between statistically versus clinical significant reduction in anxiety symptomatology scores is highlighted. Although a statistically significant post-treatment reduction in anxiety may be found in the trial, this information is often limited in terms of applicability to practice. It is useful to set an a priori outcome that is judged to be an adequate clinical response to treatment, for example, a 25% or 50% reduction in anxiety scores from baseline. In addition, it is acknowledged that broadening the scope of this review to include people with acquired brain impairment would have resulted in increased adaptability of these findings to clinical practice; on the other hand, by focusing on TBI this review was able to address issues specific to this population.

There are also areas of this research which have not been investigated. In particular, trials are needed that examine psychological treatments specifically for people with severe TBI, given that no study in this area was identified. The development of post-TBI anxiety follows a different path depending on the severity of the injury (Ponsford 1995). Individuals with severe TBI often have a distinct profile of functioning compared to people with mild to moderate TBI in terms of degree of memory, executive, and insight difficulties, which may in turn impact anxiety levels. Further trials are also needed which use paediatric populations, given that no trial was identified examining psychological treatment for anxiety in children with TBI and that interventions targeting children need to address specific developmental issues.

 

Strengths and weaknesses of included studies

A major strength of the two main trials (Bryant 2003; Tiersky 2005) is their methodological quality, assessed by the PEDro scale as moderate. Both of these studies also focused on psychological treatments which are clinically suitable, particularly to people with TBI, and recommended as being suitable for people with neurological conditions (Williams 2003a). However, the findings from this review must be viewed in light of the small sample size as well as the heterogeneous characteristics of trials published in this area (for example, the types of psychological intervention and anxiety diagnoses examined).

This review also identified 20 studies examining psychological treatment of anxiety following TBI which did not employ an RCT design, including group (non-randomised) comparisons, case series and single participant designs. This suggests that although there are considerable data available, there may be barriers to conducting research in this area preventing the use of the more powerful design of an RCT. Given that the majority of these 20 studies (80%) used single participant design, these barriers appear to lie in the inability to obtain sufficient numbers of participants for group studies. Fostering collaboration between research groups would provide an avenue to overcome this difficulty.

 

Findings in relation of previous research

These findings contribute to the understanding of psychological treatments for anxiety in people with TBI given there are no systematic reviews currently available summarising the evidence for effectiveness of these approaches with this clinical population. With only three identified trials, this review highlights that research in this area is not well developed. The ability to pool data from across studies would be greatly improved with future studies focusing on comparable psychological interventions, severity of injury of participants, and diagnosis of anxiety disorder(s).

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

 

Implications for practice

This review provides some evidence for the effectiveness of CBT for treatment of acute stress disorder following mild TBI, and CBT combined with NR for targeting general anxiety symptomatology in people with mild-moderate TBI. Additionally, when including samples of individuals with a diagnosed anxiety disorder, results indicate that treatment effects are linked to disorder rather than general anxiety, suggesting that further research examining anxiety disorders, such as PTSD, should focus on interventions which are tailored to the disorder. These conclusions are based on a small number of trials with small sample sizes (ranging from 16 to 24). More research using larger samples sizes as well as homogeneous samples and interventions are needed to confirm these findings.

 
Implications for research

This review did not pool data across studies due to the heterogeneity of studies in this area and, therefore, results of the review are based on individual studies. In order to combine data across trials we recommend further trials which focus on comparable psychological interventions, severity of injury of participants and diagnosis of anxiety disorder(s). The findings of the review also indicate that there some areas of this research which have not been examined. Additional RCTs using samples with a broader range of injury severity, anxiety diagnoses and age (including children) are needed.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

This review was supported by the Rehabilitation Studies Unit, University of Sydney and the Motor Accidents Authority of New South Wales, Australia.
We thank the Cochrane Injuries Group for assistance throughout the review process.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Appendix 1. Search strategy

MEDLINE
1 exp brain injuries/ or exp craniocerebral trauma/ or exp brain damage, chronic/
2 (TBI or CHI or ABI).tw.
3 brain impairment$.tw.
4 ((brain or head or cranial) adj5 trauma).tw.
5 ((brain or head or cranial) adj5 damage).tw.
6 ((brain or head or cranial) adj5 injur$).tw.
7 ((brain or head or cranial) adj5 disorder$).tw.
8 or/1-7
9 exp ANXIETY DISORDERS/ or exp ANXIETY/ or exp ANXIETY, SEPARATION/ or exp MANIFEST ANXIETY SCALE/ or exp TEST ANXIETY SCALE/ or exp DENTAL ANXIETY/
10 (anxiety adj5 disorder$).tw.
11 (anxiety or anxious or overanxious).tw.
12 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
13 or/9-12
14 exp intervention studies/ or exp therapeutics/ or exp family therapy/ or exp cognitive therapy/ or exp behavior therapy/
15 exp REHABILITATION/
16 exp PSYCHOTHERAPY/
17 exp PSYCHOANALYSIS/
18 exp Psychoanalytic Therapy/ or exp PSYCHOTHERAPEUTIC PROCESSES/
19 exp Counseling/
20 exp EDUCATION/
21 exp Program Evaluation/
22 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
23 ((cognitive or behavio$r) adj5 therap$).tw.
24 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
25 or/14-24
26 8 and 13 and 25

EMBASE
1 exp brain injury/ or exp head injuries/ or exp brain contusion/ or exp brain stem injury/ or exp cerebellum injury/
2 (TBI or CHI or ABI).tw.
3 brain impairment$.tw.
4 ((brain or head or cranial) adj5 trauma).tw.
5 ((brain or head or cranial) adj5 damage).tw.
6 ((brain or head or cranial) adj5 injur$).tw.
7 ((brain or head or cranial) adj5 disorder$).tw.
8 or/1-7
9 exp anxiety/
10 exp SEPARATION ANXIETY/ or "HOSPITAL ANXIETY AND DEPRESSION SCALE"/ or ANXIETY DISORDER/ or "MIXED ANXIETY AND DEPRESSION"/ or STATE TRAIT ANXIETY INVENTORY/ or ANXIETY NEUROSIS/ or GENERALIZED ANXIETY DISORDER/
11 (anxiety adj5 disorder$).tw.
12 (anxiety or anxious or overanxious).tw.
13 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
14 exp psychiatric treatment/ or exp treatment outcome/ or exp treatment failure/ or exp treatment planning/ or exp therapy/ or exp management/
15 exp behavior therapy/ or exp cognitive therapy/
16 exp REHABILITATION/
17 exp Counseling/
18 exp EDUCATION/
19 exp PSYCHOTHERAPY/
20 exp PSYCHOANALYSIS/
21 exp Family Therapy/
22 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
23 ((cognitive or behavio$r) adj5 therap$).tw.
24 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
25 or/9-13
26 or/14-24
27 8 and 25 and 26

PsycINFO
1 exp Brain Damage/ or exp Head Injuries/ or exp Traumatic Brain Injury/ or exp "Recovery (Disorders)"/
2 exp Brain Concussion/
3 (TBI or CHI or ABI).tw.
4 brain impairment$.tw.
5 ((brain or head or cranial) adj5 trauma).tw.
6 ((brain or head or cranial) adj5 damage).tw.
7 ((brain or head or cranial) adj5 injur$).tw.
8 ((brain or head or cranial) adj5 disorder$).tw.
9 or/1-8
10 exp SPEECH ANXIETY/ or exp MATHEMATICS ANXIETY/ or exp SEPARATION ANXIETY/ or exp ANXIETY MANAGEMENT/ or exp PERFORMANCE ANXIETY/ or exp ANXIETY DISORDERS/ or exp ANXIETY/ or exp TEST ANXIETY/ or exp SOCIAL ANXIETY/ or exp COMPUTER ANXIETY/ 11 exp AGORAPHOBIA/ or exp School Phobia/ or exp Elective Mutism/ or exp PANIC ATTACK/ or exp PANIC/ or exp Hypochondriasis/ or exp COMPULSIONS/ or exp OBSESSIONS/
12 (anxiety adj5 disorder$).tw.
13 (anxiety or anxious or overanxious).tw.
14 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
15 exp PSYCHOSOCIAL REHABILITATION/ or exp COGNITIVE REHABILITATION/ or exp NEUROPSYCHOLOGICAL REHABILITATION/ or exp REHABILITATION EDUCATION/ or exp REHABILITATION/
16 exp OUTPATIENT TREATMENT/ or exp INTERDISCIPLINARY TREATMENT APPROACH/ or exp MULTIMODAL TREATMENT APPROACH/ or exp TREATMENT/ or exp TREATMENT EFFECTIVENESS EVALUATION/
17 exp Psychotherapy/ or exp Psychotherapeutic Processes/ or exp Psychotherapists/
18 exp Cognitive Behavior Therapy/ or exp Cognitive Therapy/ or exp Psychoeducation/ or exp Behavior Therapy/ or exp mental health program evaluation/ or exp family therapy/
19 exp PSYCHOTHERAPEUTIC OUTCOMES/ or exp PSYCHOTHERAPEUTIC TECHNIQUES/ or exp PSYCHOTHERAPEUTIC COUNSELING/ (35059)
20 exp INTERVENTION/
21 exp Education/
22 exp Counseling/ or exp program evaluation/
23 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
24 ((cognitive or behavio$r) adj5 therap$).tw.
25 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
26 or/10-14
27 or/15-25
28 9 and 26 and 27

CINAHL
1 exp brain injuries/ or exp head injuries/ or exp brain damage, chronic/ (10249)
2 (TBI or CHI or ABI).tw.
3 brain impairment$.tw.
4 ((brain or head or cranial) adj5 trauma).tw.
5 ((brain or head or cranial) adj5 damage).tw.
6 ((brain or head or cranial) adj5 injur$).tw.
7 ((brain or head or cranial) adj5 disorder$).tw.
8 or/1-7
9 exp anxiety/ or exp anxiety disorders/ or exp self-rating anxiety scale/ or exp separation anxiety/
10 (anxiety adj5 disorder$).tw.
11 (anxiety or anxious or overanxious).tw.
12 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
13 or/9-12
14 exp treatment outcomes/
15 exp treatment failure/
16 exp intervention trials/
17 exp cognitive therapy/ or exp behavior therapy/ or exp family therapy/
18 exp REHABILITATION/
19 exp PSYCHOTHERAPY/
20 exp Program Evaluation/
21 exp Counseling/
22 exp EDUCATION/
23 exp PSYCHOANALYSIS/
24 exp Psychotherapeutic Processes/ or exp therapeutics/
25 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
26 ((cognitive or behavio$r) adj5 therap$).tw.
27 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
28 or/14-27
29 8 and 13 and 28

AMED
1 exp brain injuries/
2 exp head injuries/
3 exp brain disease/
4 (TBI or CHI or ABI).tw.
5 brain impairment$.tw.
6 ((brain or head or cranial) adj5 trauma).tw.
7 ((brain or head or cranial) adj5 damage).tw.
8 ((brain or head or cranial) adj5 injur$).tw.
9 ((brain or head or cranial) adj5 disorder$).tw.
10 or/1-9
11 exp anxiety/
12 exp Anxiety disorders/
13 (anxiety adj5 disorder$).tw.
14 (anxiety or anxious or overanxious).tw.
15 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
16 or/11-15
17 exp Therapy computer assisted/ or exp program evaluation/ or exp treatment outcome/ or exp program evaluation/
18 exp Behavior therapy/
19 exp Cognitive therapy/ or Psychotherapy/
20 exp Counseling/
21 exp Education/
22 exp Psychotherapy/
23 exp psychosomatic therapies/
24 exp Psychoanalytic therapy/
25 exp Family therapy/
26 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
27 ((cognitive or behavio$r) adj5 therap$).tw.
28 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
29 or/17-28
30 10 and 16 and 29

ERIC
1 exp head injuries/
2 exp neurological impairments/
3 (TBI or CHI or ABI).tw.
4 brain impairment$.tw.
5 ((brain or head or cranial) adj5 trauma).tw.
6 ((brain or head or cranial) adj5 damage).tw.
7 ((brain or head or cranial) adj5 injur$).tw.
8 ((brain or head or cranial) adj5 disorder$).tw.
9 or/1-8
10 exp SEPARATION ANXIETY/ or exp COMPUTER ANXIETY/ or exp SCIENCE ANXIETY/ or exp ANXIETY/ or exp MATHEMATICS ANXIETY/ or exp TEST ANXIETY/
11 exp Mental Disorders/ or exp Emotional Disturbances/
12 (anxiety adj5 disorder$).tw.
13 (anxiety or anxious or overanxious).tw.
14 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
15 or/10-14
16 exp intervention/ or exp outcomes of treatment/ or exp therapy/
17 exp REHABILITATION/
18 exp PSYCHOTHERAPY/ or exp behavior modification/
19 exp Psychiatry/
20 exp Counseling/
21 exp EDUCATION/
22 exp program evaluation/
23 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
24 ((cognitive or behavio$r) adj5 therap$).tw.
25 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
26 or/16-25
27 9 and 15 and 26

DARE
1 (TBI or CHI or ABI).tw.
2 brain impairment$.tw.
3 ((brain or head or cranial) adj5 trauma).tw.
4 ((brain or head or cranial) adj5 damage).tw.
5 ((brain or head or cranial) adj5 injur$).tw.
6 ((brain or head or cranial) adj5 disorder$).tw.
7 or/1-6
8 (anxiety adj5 disorder$).tw.
9 (anxiety or anxious or overanxious).tw.
10 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
11 or/8-10
12 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
13 ((cognitive or behavio$r) adj5 therap$).tw.
14 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
15 or/12-14
16 7 and 11 and 15

CENTRAL
1 exp brain injuries/
2 exp Brain Damage, Chronic/
3 exp craniocerebral trauma/
4 (TBI or CHI or ABI).tw.
5 brain impairment$.tw.
6 ((brain or head or cranial) adj5 trauma).tw.
7 ((brain or head or cranial) adj5 damage).tw.
8 ((brain or head or cranial) adj5 injur$).tw.
9 ((brain or head or cranial) adj5 disorder$).tw.
10 or/1-9
11 exp Anxiety Disorders/
12 exp anxiety/
13 (anxiety adj5 disorder$).tw.
14 (anxiety or anxious or overanxious).tw.
15 (panic attack$ or agoraphobia$ or specific phobia$ or social phobia$ or obsessive compulsive disorder$ or posttraumatic stress disorder$ or post traumatic stress disorder$ or acute stress disorder$ or generali$ed anxiety disorder$ or separation anxiety disorder$ or school phobia$ or overanxious disorder$ or selective mutism).tw.
16 or/11-15
17 exp cognitive therapy/ or exp behavior therapy/ or exp family therapy/
18 exp combined modality therapy/
19 exp psychotherapy/ or exp psychoanalysis/
20 exp counseling/ or exp education/
21 exp program evaluation/ or exp treatment outcome/ or exp therapeutics/
22 exp rehabilitation/
23 (training or treatment$ or rehab$ or remed$ or program$ or interven$ or therap$ or approach$ or techniq$ or counsel$ or modificat$ or strateg$ or manag$).tw.
24 ((cognitive or behavio$r) adj5 therap$).tw.
25 (cognitive restructur$ or graded expos$ or relaxation or hyperventilation control).tw.
26 or/17-25
27 10 and 16 and 26

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Last assessed as up-to-date: 1 May 2007.


DateEventDescription

14 March 2012AmendedAdditional tables linked to text.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Protocol first published: Issue 2, 2005
Review first published: Issue 3, 2007


DateEventDescription

11 July 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

CS and RT were jointly responsible for reviewing papers.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Internal sources

  • Rehabilitation Studies Unit, University of Sydney and Royal Rehabilitation Centre Sydney, Australia.

 

External sources

  • Motor Accidents Authority of New South Wales, Australia.

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Bryant 2003 {published data only}
Helffenstein 1982 {published data only}
  • Helffenstein DA, Wechsler FS. The use of interpersonal process recall (IPR) in the remediation of interpersonal and communication skill deficit in the newly brain-injured. Clinical Neuropsychology 1982;4(3):139-43.
Tiersky 2005 {published data only}
  • Tiersky LA, Anselmi V, Johnston MV, Kurtyka J, Roosen E, Schwartz T, et al. A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2005;86:1565-74.

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Ackerman 2004 {published data only}
  • Ackerman RJ. Applied psychophysiology, clinical biofeedback, and rehabilitation neuropsychology: a case study - mild traumatic brain injury and post traumatic stress disorder. Physical Medicine and Rehabilitation Clinics of North America 2004;15:919-31.
Adelbratt 2000 {published data only}
Bedard 2003 {published data only}
  • Bedard M, Felteau M, Mazmanian D, Fedyk K, Klein R, Richardson J, et al. Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. Disability and Rehabilitation 2003;25:722-31.
Drummond 1988 {published data only}
  • Drummond LM, Gravestock S. Delayed emergence of obsessive-compulsive neurosis following head injury: case report and review of its theoretical implications. British Journal of Psychiatry 1988;153:839-42.
Gurr 2001 {published data only}
Hodgson 2005 {published data only}
  • Hodgson J, McDonald S, Tate R, Gertler P. A randomised controlled trial of a cognitive-behavioural therapy program for managing social anxiety after acquired brain injury. Brain Impairment 2005;6:169-80.
Holland 1999 {published data only}
Johnson 1987a {published data only}
  • Johnson DA, Newton A. HIPSIG: A basis for social adjustment after head injury. British Journal of Occupational Therapy 1987;50:47-52.
Johnson 1987b {published data only}
King 2002 {published data only}
  • King NS. Perseveration of traumatic re-experiencing in PTSD: a cautionary note regarding exposure based psychological treatments for PTSD when head injury and dysexecutive impairment are also present. Brain Injury 2002;16:65-74.
Ko 1997 {published data only}
  • Ko SM. Obsessive compulsive disorder following head injury. International Journal of Clinical Practice 1997;51:336-8.
Koder 1998 {published data only}
  • Koder DA. Treatment of anxiety in the cognitively impaired elderly: can cognitive-behavior therapy help?. International Psychogeriatrics 1998;10:173-82.
Lysaght 1990 {published data only}
  • Lysaght R, Bodenhamer E. The use of relaxation training to enhance functional outcomes in adults with traumatic head injuries. The American Journal of Occupational Therapy 1990;44:797-802.
Mateer 2005 {published data only}
  • Mateer CA, Sira CS, O'Connell ME. Putting humpty dumpty together again: the importance of integrating cognitive and emotional interventions. Journal of Head Trauma Rehabilitation 2005;20:62-75.
McGrath 1997 {published data only}
  • McGrath J. Cognitive impairment associated with post-traumatic stress disorder and minor head injury: a case report. Neuropsychological Rehabilitation 1997;7:231-9.
McGrath 1999 {published data only}
  • McGrath JR, Adams L. Patient-centered goal planning: a systematic psychological therapy. Topics in Stroke Rehabilitation 1999;6:43-50.
McMillian 1991 {published data only}
McMillian 1996 {published data only}
McNeil 1996 {published data only}
  • McNeil JE, Greenwood R. Can PTSD occur with amnesia for the precipitating event. Cognitive Neuropsychiatry 1996;1:239-46.
Suhr 1999 {published data only}
  • Suhr J, Anderson S, Tranel D. Progressive muscle relaxation in the management of behavioural disturbance in Alzheimer's disease. Neuropsychological Rehabilitation 1999;9:31-44.
Takano 2000 {published data only}
  • Takano M, Ando S. Application of autogenic training to patients with cerebral contusion and cerebral infarction. Japanese Journal of Autogenic Therapy 2000;18:33-9.
Williams 2003a {published data only}
  • Williams WH, Evans JJ, Fleminger S. Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: an overview and a case illustration of obsessive-compulsive disorder. Neuropsychological Rehabilitation 2003;13:133-48.
Williams 2003b {published data only}
  • Williams WH, Evans JJ, Wilson BA. Neurorehabilitation for two cases of post-traumatic stress disorder following traumatic brain injury. Cognitive Neuropsychiatry 2003;8:1-18.
Youngson 1994 {published data only}
  • Youngson HA, Alderman N. Fear of incontinence and its effects on a community-based rehabilitation programme after severe brain injury: successful remediation of escape behaviour using behaviour modification. Brain Injury 1994;8:23-36.
Zencius 1990 {published data only}
  • Zencius A, Wesolowski MD. Brief report: using stress management to decrease inappropriate behavior in a brain injured adult. Behavioral Residential Treatment 1990;5:61-4.

Additional references

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
APA 1994
  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th Edition. Washington DC: Author, 1994.
Balon 2004
Bowen 1998
  • Bowen A, Neumann V, Conners M, Tennant A, Chamberlain MA. Mood disorders following traumatic brain injury: Identifying the extent of the problem and the people at risk. Brain Injury 1998;12:177-90.
Bryant 2000
Deacon 2004
Fann 1995
  • Fann JR, Katon WJ, Uomoto JM, Esselman PC. Psychiatric disorders and functional disability in outpatients with traumatic brain injuries. The American Journal of Psychiatry 1995;152(1):493-9.
Gainotti 1993
Hibbard 1998
Hiott 2002
Kay 1993
  • Kay T, Harrington DE, Adams R, Anderson T, Berrol S, Cicerone K, et al. Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation 1993;8(3):86-7.
Kendall 1996
Kessler 2001
  • Kessler R, Soukup J, Davis RB, Foster DF, Wilkey SA, Van Rompay M, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. The American Journal of Psychiatry 2001;158(2):289-94.
Lishman 1973
Maher 2003
Manchester 2001
  • Manchester D, Woods RL. Applying cognitive therapy in neurobehavioural rehabilitation. Neurobehavioural disability and social handicap following traumatic brain injury. Hove, UK: Psychology Press, 2001.
Ponsford 1995
  • Ponsford J, Sloan S, Snow P. Traumatic brain injury: Rehabilitation for everyday adaptive living. Hove, UK: Psychology Press, 1995.
Ruck 2003
  • Ruck C, Andreewitch S, Flyckt K, Edman G, Nyman H, Meyerson BA, et al. Capsulotomy for refractory anxiety disorders: Long term follow-up of 26 patients. The American Journal of Psychiatry 2003;160(3):513-21.
Van Reekum 1996
Verhagen 1998
  • Verhagen AP, de Vet HCW, de Bie RA, Kessels AGH, Boers M, Bouter M, et al. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. Journal of Clinical Epidemiology 1998;51(12):1235-41.
WHO 1992
  • World Health Organization (WHO). The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization, 1992.